Impact of a Chronic Total Coronary Occlusion on Ventricular Arrhythmias and Long-Term Mortality in Patients With Ischemic Cardiomyopathy and an ICD
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Previous studies report conflicting results about a higher incidence of ventricular arrhythmias in patients with a chronic total coronary occlusion (CTO). We aimed to investigate this association in a large cohort of implantable cardioverter defibrillator patients with long-term follow-up.
METHODS AND RESULTS
All consecutive patients from 1992 onwards who underwent implantable cardioverter defibrillator implantation for ischemic cardiomyopathy at the Leiden University Medical Center were evaluated. Coronary angiograms were reviewed for the presence of a CTO. The occurrence of ventricular arrhythmias and survival status at follow-up were compared between patients with and patients without a CTO. A total of 722 patients constitute the study cohort (age 66±11 years; 84% males; 74% primary prevention, median left ventricular ejection fraction 30% [first-third quartile: 25-37], 44% received a cardiac resynchronization therapy defibrillator). At baseline, 240 patients (33%) had a CTO, and the CTOs were present for at least 44 (2-127) months. The median follow-up duration was 4 (2-6) years. On long-term follow-up, CTO patients had a higher crude appropriate device therapy rate (37% versus 27%, P=0.010) and a lower crude survival rate (51% versus 67%, P<0.001) compared with patients without a CTO. Corrected for baseline characteristics including left ventricular ejection fraction, the presence of a CTO was an independent predictor for appropriate device therapy.
CONCLUSIONS
The presence of a CTO in implantable cardioverter defibrillator patients was associated with more appropriate device therapy and worse prognosis at long-term follow-up. Further investigation is warranted regarding a potential beneficial effect of CTO revascularization on the incidence of ventricular arrhythmias.
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Additional Info
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Evaluation of the Impact of a Chronic Total Coronary Occlusion on Ventricular Arrhythmias and Long-Term Mortality in Patients With Ischemic Cardiomyopathy and an Implantable Cardioverter-Defibrillator (the eCTOpy-in-ICD Study)
J Am Heart Assoc 2018 May 02;7(10)e008609, IM van Dongen, D Yilmaz, J Elias, BEPM Claessen, R Delewi, RE Knops, AAM Wilde, L van Erven, MJ Schalij, JPS HenriquesFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Coronary chronic total occlusions (CTOs) have been associated with ischemia in virtually all supplied myocardial territories (assuming that they are viable). Ischemia may lead to symptoms, such as angina and dyspnea, worsening of ventricular function, and may predispose to arrhythmias. Several (but not all) prior studies of ischemic cardiomyopathy patients have shown an association between presence of a coronary CTO and ventricular arrhythmias/appropriate ICD shocks. This is exactly what was shown in the eCTOpy-in-ICD study, which also showed an association of CTOs with higher mortality.
Does this mean that all CTOs in ischemic cardiomyopathy patients should be revascularized? Not quite yet. CTOs could just be a marker of worse overall clinical condition and not the cause of the arrhythmias. The CTO-supplied territory may be nonviable. And CTO PCI can be complex and may carry increased risk in cardiomyopathy patients. At the same time, there are cases of recurrent ventricular tachycardia and ICD storm that resolved after CTO recanalization.
Improving symptoms remains the main indication for recanalizing coronary CTOs. Reducing the risk for ventricular arrhythmias is an appealing, yet unproven additional indication, that should likely be limited to the few patients with high arrhythmia burden and viable myocardium in whom the anticipated benefits of CTO recanalization exceed the potential risks.